System and apparatus for utilization review of medical claims

• US 6,324,516 B1
• Filed: 04/30/1998
• Issued: 11/27/2001
• Est. Priority Date: 06/11/1997
• Status: Expired due to Term

• Current Assignee: Fair Isaac Corporation
• Original Assignee: CompReview, Inc. (Fair Isaac Corporation)
• Inventors: Smith, Scott R., Altwies, Diane C., Kaaren, Robert L., Delizio, Michelle T., Shults, Matthew P., Munayyer, Mishel E.
• Primary Examiner(s): Hafiz, Tariq R.
• Assistant Examiner(s): HARLE, JENNIFER I
• Application Number:
  US09/070,272
• Time in Patent Office: 1,307 Days
• Field of Search: 705/1, 705/2, 705/3, 705/4, 705/8, 705/9
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03

Abstract

A medical cost containment system for ensuring that the anticipated cost savings from utilization review (UR) agreements are actually realized. The UR agreements are essentially contractual agreements that specify the type and quantity of medical treatments relating to a specific claim resulting from a specific injury. Each UR agreement comprises a claim number, a procedure code describing the particular medical service authorized, and some indication as to dates or quantity of service authorized. All of the UR agreements are stored in a UR database. When a medical bill is received by the insurance company, the bill is entered in to the computer. The cost containment system searches all UR agreements in the UR database which have the same claim number as the claim number on the bill. For each item in the medical bill, the system finds the UR agreement which most closely matches the procedure code in the line item and various other criteria, such as the dates of treatment. The system then checks to ensure that the item in the bill is authorized by the UR agreement. If the item is authorized, then payment is made. If the item is not authorized, then the item is flagged for further review.

Claims

1. A medical cost containment system for allowing a medical cost payor to correlate medical bills from a medical service provider with utilization review (UR) agreements between said payor and said provider, said cost containment system comprising:

a computer processor operatively coupled to a memory;

a UR database containing said UR agreements;

database access software stored within said memory, said database access software configured to allow retrieval of records from said UR database;

an invoice from said provider stored within said memory, said invoice having at least one itemized request for payment; and

correlation software stored within said memory, said correlation software configured to correlate said itemized request to said UR agreements;

said correlation software further configured to at least adjust an amount of said at least one itemized request for payment in accordance with said UR agreement or approve payment of at least one itemized request for payment in accordance with said UR agreement or flag at least one itemized request for payment for further review in accordance with said UR agreement.

2. The medical cost containment system of claim 1, wherein said itemized request is stored within said memory using a first numeric code, said first numeric code being selected from a table, said table listing specified numeric codes and medical services corresponding to said specified numeric codes, said specified numeric codes chosen such that similar medical services are represented by specified numeric codes that differ only in the least significant digits, said UR agreements stored in said UR database using second numeric codes, said second numeric codes selected from said table, said correlation software correlating said UR agreements with said itemized request for payment by matching as many significant digits as possible from said first numeric code with as many significant digits as possible from said second numeric codes.

3. The medical cost containment system of claim 1, wherein said UR database prioritizes said UR agreements.

4. The medical cost containment system of claim 1, wherein said UR agreements comprise descriptions of specific medical treatments and services and the quantity, duration, or dates of said medical treatments and services.

5. The medical cost containment system of claim 4, wherein said descriptions of specific medical treatments and services comprise alphanumeric codes.

6. The medical cost containment system of claim 5, wherein said alphanumeric codes comprise AMA CPT-4 codes.

7. A medical cost containment system for allowing a medical cost payor to correlate medical bills from a medical service provider with utilization review (UR) agreements between said payor and said provider, said cost containment system comprising:

a computer processor operatively coupled to a memory;

a UR database containing said UR agreements;

database access software stored within said memory, said database access software configured to allow retrieval of records from said UR database;

an invoice from said provider stored within said memory, said invoice having at least one itemized request for payment; and

correlation software stored within said memory, said correlation software configured to determine a probability of correlation between each of said itemized requests and each of said UR agreements;

said correlation software further configured to at least adjust an amount of said at least one itemized request for payment in accordance with said UR agreement or approve payment of at least one itemized request for payment in accordance with said UR agreement or flag at least one itemized request for payment for further review in accordance with said UR agreement.

8. A method for attempting to ensure that, in a managed care system, a utilization review (UR) agreement for medical services is properly enforced such that an anticipated cost savings under said UR agreement are realized, said method comprising the steps of:

storing said UR agreement in a computerized UR database;

entering an itemized request for payment from a bill for medical services into a computer;

correlating said UR agreement with said itemized request for payment;

determining whether said itemized request for payment is proper under said UR agreement; and

adjusting an amount of said at least one itemized request for payment in accordance with said UR agreement or approving payment of at least one itemized request for payment in accordance with said UR agreement or flagging at least one itemized request for payment for further review in accordance with said UR agreement.

9. The method of claim 8 wherein said UR database contains a plurality of UR agreements.

10. The method of claim 9, further comprising the step of prioritizing the correlation between said itemized request for payment and said plurality of UR agreements stored in said UR database.

11. The method of claim 8, wherein said UR database is a distributed database.

12. The method of claim 8, wherein said UR agreements comprise descriptions of specific medical treatments and services and the quantity, duration, or dates of said medical treatments and services.

13. The method of claim 12, wherein said descriptions of specific medical treatments and services comprise alphanumeric codes.

14. The method of claim 13, wherein said alphanumeric codes comprise AMA CPT-4 codes.

15. The method of claim 14, wherein said itemized request for payment comprises AMA CPT-4 codes.

16. The method of claim 15, wherein said step of correlating said UR agreements with said itemized request for payment comprises matching as many digits as possible between said AMA CPT-4 code in said UR agreement and said AMA CPT-4 code in said itemized request for payment.

17. The method of claim 14, wherein said alphanumeric codes comprise statutory Relative Value Schedule (RVS) Codes.

18. The method of claim 17, wherein said step of correlating said UR agreements with said itemized request for payment comprises matching as many digits as possible between said RVS code in said UR agreement and an RVS code in said itemized request for payment.

19. The method of claim 17, wherein said step of correlating said UR agreements with said itemized request for payment comprises matching as many significant digits as possible between said RVS code in said UR agreement and an RVS code in said itemized request for payment.

20. A method for correlating imperfect matches between coded service items in a bill and a service authorization agreement, said method comprising the steps of:

storing said service authorization agreement in a computerized agreement database;

entering into a computer an itemized request for payment from said bill;

correlating said service authorization agreement with said itemized request for payment; and

determining whether said itemized request for payment is proper under said service authorization agreement.

21. The method of claim 20 wherein said agreement database contains a plurality of service authorization agreements.

22. The method of claim 21, further comprising the step of prioritizing the correlation between said itemized request for payment and said plurality of service authorization agreements stored in said agreement database.

23. The method of claim 20, wherein said authorization database is a distributed database.

24. The method of claim 20, wherein said service authorization agreements comprise descriptions of specific services, said descriptions comprising a quantity, a duration, or a date of said services.

25. The method of claim 24, wherein said descriptions of specific services comprise first alphanumeric codes.

26. The method of claim 25, wherein said itemized request for payment comprises a second alphanumeric code.

27. The method of claim 26, wherein said step of correlating said service authorization agreements with said itemized request for payment comprises matching as many characters as possible between said alphanumeric code in said service authorization agreement and said alphanumeric code in said itemized request for payment.

28. The method of claim 27, wherein said alphanumeric codes comprise statutory Relative Value Schedule (RVS) Codes.

29. The method of claim 27, wherein said alphanumeric codes comprise AMA CPT-4 codes.

30. The method of claim 26, wherein said alphanumeric codes comprise numeric codes chosen such that similar services are represented by numeric values that differ only in the least significant digits, such that said step of correlating said service authorization agreements with said itemized request for payment comprises matching as many digits as possible between said second alphanumeric code and said first alphanumeric codes.

31. The method of claim 30, further comprising the step of using additional data to determine correlation between said request for payment and said service authorization agreements, said additional data comprising dates of service, quantity of service, and duration of service.